Seriously, How can I Stop and Prevent Bruising when I get Cosmetic Fillers like Juvederm, Esthelis or Radiesse? The Truth! An Editorial.

If you are considering a Botox injection in Ottawa, let me start by telling you this, every time a needle is placed in your skin there is a risk of bruising. To quote a wonderfully cranky Cape Bretoner I once knew, “There are no ifs ands or buts about it!” Ok, maybe that is harsh but in reality I think we all understand that injecting any material into the skin has the risk of causing bruising. This can include getting an IV, getting blood taken, a vaccination or fillers placed into wrinkles in your face. In addition to this, there is a risk of bruising after plastic surgery and cosmetic surgery in general. Fortunetly, there are ways to help reduce the chance of bruising and hopefully prevent and stop bruising after plastic surgery.  Although the principles used to prevent and stop bruising in this article apply to surgeries like nose jobs (rhinoplasty), face lifts, eye brow lifts, forehead lifts and even Botox, this article is focused on cosmetic fillers in general.

When I meet a patient who is interested in fillers, as an ethical physician I am clear to explain all potential risks. I think some people don’t like hearing these things however to be a truly informed patient, this is a conversation that we must have. The risk of bruising is low, however it happens to everyone. I have a few common things I say to patients about small complications like bruising with Fillers or Botox.

#1 – No matter what any other doctor says, we all have bruised someone at some point. If someone tells you they never caused a bruise, it is not true, that I can guarantee. It happens, we cannot see under your skin. If you get Botox or Filler regularly, at some time you will get a bruise.  Our job is to reduce the risk as much as possible, which will be the main purpose of this article.

#2 – If you do get a bruise, the odds are that it will be small and easily concealed.

For this article in my scientific editorial series, I am going to discuss a paper by Dr Schlesinger, Cohen and Ellison published in the Journal of Drugs in Dermatology in 2013. The purpose of the article was to discuss ways to limited and treat bruising that may occur due to cosmetic fillers such as Juvederm, Esthelis and Radiesse.

The authors discussed three aspects of filler injection and their relationship to bruising:

1 – Pre-Procedural (pre-filler injection) considerations

2 – Intra-Procedural (during the actual injection) considerations

3 – Post-Procedural (after the injection) considerations

 

Part 1a – Pre-Filler Injection Issues and Treatments That Increase the Risk of Bleeding

There are a number of things we can do to help reduce the risk of bleeding, particularly before we inject these products.  Many of these considerations are related to medications and the risk of increasing bruising.

1. Medications
   1. NSAIDS – If you take medications like Ibuprofen(Advil), aspirin or naproxen (Aleve) your risk of getting a bruise increases. These medications prevent blood cells (platelets), that normally are responsible for stopping bleeding, to not function properly. Because of this, bruising risk increases. You should talk to your doctor prior to stopping any medication as some people need to be on these medications. However, if you are worried about the discomfort of filler injections, its best to take Tylenol before the procedure and not one of the medication listed above. If you do stop Aspirin, it takes about 5-7 days for the risk of bruising to return to normal. Other medications like Ibuprofen and naproxen should be stopped the day before the injection of filler.
   2. Anti-coagulant medications – These are medications that are often used in people to prevent complications of heart attacks, for people with heart problems, prior strokes and other medical issues. This includes many medications that prevent the blood from clotting. Although this can increase your risk of bruising, these are medications that can be life saving and thus should not be stopped unless your treating physician says it is ok to do so. Never stop these medications without talking to your primary care physician.
2. Vitamins and Supplements

There are so many vitamins and supplements on the market these days it is often difficult to know what is actually in many of them. Many supplements are not controlled by Health Canada thus their ingredients, concentration and dose can vary widely across manufacturers.  Another problem is research. Although many of these supplements have been shown to increase bleeding time, it is not known if they actually increase your chance of bruising with fillers like Juvederm, Esthelis or Radiesse. My advice to patients, is to be cautious and stop these supplements if possible. If  you are under the care of a Naturopathic Doctor, it is best to discuss this with them as well to ensure they do not conflict with other treatments. I recommend stopping all supplements 7 days before the treatment with the cosmetic filler.

1. Garlic – This can act similar to aspirin and prevent your blood from clotting. It has powerful properties and if used as a supplement can increase your risk of bruising. The higher the dose of garlic, the greater the chance you will bruise during a filler injection.
2. Ginko and Ginseng – These too have powerful effects on our bodies ability to stop bleeding. They can both increase your risk of bruising after an injection of filler like Juvederm, Esthelis or Radiesse. In addition to the effect on bleeding, Ginseng has also been shown to increase blood pressure in some people, which can also increase your risk of bruising.
3. Ginger Root – Although ginger is known to increase bleeding time, a recent study was performed and found no difference in bruising in patients who take ginger root versus those who do not. Therefore, it is likely ginger is safe.
4. Vitamin E – This has also been shown to increase bleeding time and thus should be stopped. Unfortunately, there is little research in this area.
5. Multi-vitamins – as mentioned above, it can be unclear what is in some of these products therefore it is best to stop them prior to an injection with a dermal filler.

Alcohol

There is some research suggesting that alcohol can reduce the body’s ability to stop bleeding.  Many plastic surgeons and cosmetic surgeons who inject filler recommend no alcohol 2 days before and 2 days after the treatment to reduce the risk of bruising.

Part 1b – Pre-Filler Injection Issues and Treatments That Reduce the Risk of Bleeding

Although there are many things that increase your bruising risk, there are also some supplements that have the potential to reduce the risk of bleeding. However, the difficulty lies in what us physicians call evidence, specifically research. Many of these products have not been researched well enough. Because of this, it is difficult to know if they have a real effect on bruising.

There are three supplements that are discussed by these authors.

1. Alfalfa – it has a large amount of Vitamin K, which can reduce bleeding time in some people. There is no research looking into the effect of this with fillers.
2. Bromelain – This is a supplement from pineapples. The authors of this review paper note that there is some evidence that if can reduce bruising and make a bruise go away quicker. I did a search on pubmed.com (the site that physicians use to search medical research studies) there are no studies looking at Bromelain and Bruising.
3. Arnica – This is probably the most common supplement for bruising. In fact, we use it in our clinic for surgery patients. The issue is, if you look at the research, there is limited evidence that Arnica works and thus remains controversial.  Nevertheless, many people continue to use it.  Perhaps in a future article, I will do a review of some of the bigger research studies looking into the use of arnica for plastic surgery, cosmetic surgery and injection of fillers.
4. Cold Packs – these are often before the injection to reduce pain and bruising. Cold packs work by causing small blood vessels to contract and become even smaller. Similar to the supplements used above, there is no research into cold packs.

Part 2 – Intra-Filler Injection Issues and Treatments (During the injection)

Now it is time for the actual injection, this article now discusses some things we can do during the injection of the filler to reduce bruising.

• Technique of the Filler Injector

The authors note that an experienced injector is crucial. I would agree with this. As someone who has injected hundreds of patients, like everything you do in life your skills improve over time.  We learn new techniques and refine our old techniques.  This may seem obvious, but there are many techniques cosmetic surgeons and plastic surgeons can use when injecting fillers. Some of these techniques may increase the risk of bruising.  With respect to technique, there are things that may increase the risk of bruising.  “Fanning” the needle (moving it around too much in the skin), rapid injection of the filler and large amounts of injected filler are thought to increase the risk of bruising when injecting fillers.  If you notice your injector doing multiple needle pokes and injecting in a straight line, it is likely they know what they are doing and will reduce the risk of bruising for you.  Even though you have more small little injection points, it likely results in less bruising.

• Experience of the Filler Injector

In addition to the technique of the injection, plastic surgeons, head and neck surgeons and cosmetic surgeons all have a very detailed understanding of the anatomy of the face. Knowing where blood vessels are located can reduce the risk of bruising. As a Head and Neck Surgeon, I am fortunate to perform surgeries on the face and neck 100% of the time. This provides me with considerable experience with facial anatomy.

• The use of a Cannula versus a Needle for Filler Injection

A more recent development in filler injection is the use of a device called a blunt tipped cannula. This is like a needle, however it does not have a sharp end. The benefit of this is that when it is in your skin it pushes blood vessels aside rather than cut into them. This can reduce the risk of bruising and decrease pain. Plastic surgeons and cosmetic surgeons who use blunt tip cannulas for the injection of fillers like Juvederm, Esthelis or Radiesse often report less bruising.  The downside of the cannulas is that you need to first poke a hole in the skin with a larger needle to allow access for the cannula. This is not a big deal, but it just means you still need a needle poke!

• Cooling the Skin

Finally, cooling the skin during/after the injection can reduce discomfort and cause small blood vessels to shrink. This is thought to result in reducing the risk of bleeding and bruising. Cooling or ice-packs are very popular for both Botox injections as well as Juvederm and filler injections.

 

Part 3 – Post-Filler Injection Issues and Treatments

At this point, the article discusses what you can do after the injection of fillers Juvederm, Esthelis or Radiesse.    What if you have a bruise and want it to go away quicker? The authors describe two main options for treatment, treatments you apply to the skin and laser treatments.

For treatments you put on the skin, some people use Vitamin K. One study demonstrated that Vitamin K applied to the skin does reduce the signs of bruising, although this is controversial as other studies did not demonstrate an effect.

One type of laser called Pulsed-Dye laser has been used to reduce the signs of bruising.  Using this laser in the first few days of bruising can result in a significant decrease in the signs of severe bruising.  This can reduce bruising by over 60% compared to no treatment.  It is thought that the laser targets the pigment in the skin that causes the bruising.

Summary

Bruising after the injection of cosmetic filler like Juvederm, Esthelis or Radiesse is common. Most people will develop a small bruise and in rare cases larger bruises can form. There are methods that we can use to reduce the risk of bruising.

However, in the end, it is often difficult to prevent bruising in all cases. The goal as a cosmetic surgeon injecting these fillers is to do what we can to minimize the risk of bruising. The Keys are to stop medications and supplements that increase bruising, use proper technique by an experienced injector and if you do bruise, consider using either vitamin K gel or PD Laser treatment.  In the end, you must have an honest discussion with your treating cosmetic surgeon or plastic surgeon.

Although this article focuses on fillers, the principles used to reduce bruising can be applied to any form of plastic surgery, cosmetic surgery or any other type of facial plastic surgery. Whether it be a nose job (rhinoplasty), facelift, eye lid surgery or a forehead lift these general principles apply.  There are so many factors that come into play with facial plastic surgery and bruising it is impossible to predict and prevent all of them. Our goal as ethical, experienced and knowledgeable facial plastic surgeons is to ensure we provide our Botox injections patients in Ottawa with all this information ahead of time so we can plan surgery together with the goal of limiting complications.

James P. Bonaparte, MD, MSc, FRCSC
Head and Neck Surgery
practicing in Facial Plastic and Reconstructive Surgery
Assistant Professor, University of Ottawa
Ottawa, Ontario, Canada